Healthcare Provider Details

I. General information

NPI: 1467972794
Provider Name (Legal Business Name): KIMBERLY ANN GILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date: 11/01/2023
Reactivation Date: 11/21/2023

III. Provider practice location address

327 W GORDON AVE STE 2
LAYTON UT
84041-2381
US

IV. Provider business mailing address

862 S MAIN ST
BRIGHAM CITY UT
84302-3320
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-1062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: